The four UK health systems Learning from each other Author Nicholas Timmins The King’s Fund is an Published by independent charity working to The King’s Fund improve health and health care in 11–13 Cavendish Square England. We help to shape policy London W1G 0AN and practice through research and analysis; develop individuals, Tel: 020 7307 2591 teams and organisations; promote Fax: 020 7307 2801 understanding of the health and www.kingsfund.org.uk social care system; and bring people together to learn, share © The King’s Fund 2013 knowledge and debate. Our vision is that the best possible care is First published 2013 by The King’s Fund available to all. Charity registration number: 1126980 All rights reserved, including the right of reproduction in whole or in part in any form ISBN: 978 1 909029 09 5 A catalogue record for this publication is available from the British Library Available from: The King’s Fund 11–13 Cavendish Square London W1G 0AN Tel: 020 7307 2591 Fax: 020 7307 2801 Email: [email protected] www.kingsfund.org.uk/publications Edited by Anna Brown Typeset by Grasshopper Design Company Printed in the UK by The King’s Fund Contents About the author iv Preface v Introduction 1 Changes since devolution 3 Finance 7 Politics 9 Lessons and opportunities 13 Markets and personal care 13 Targets and public service agreements 13 Data and transparency 14 Health technology assessment 15 Inspection and regulation 15 Public health 16 Workforce and size 16 Integrated care 17 Prescription and car park charges 18 Hospital reconfiguration 19 Management and bureaucracy 20 Conclusion 22 References 24 © The King’s Fund 2013 About the author Nicholas Timmins is a senior fellow at The King’s Fund. Between 1996 and 2011 he was public policy editor of the Financial Times. He has written extensively on public and private health care. He is also a senior fellow at the Institute for Government, and a visiting professor in social policy at the London School of Economics, and in public management at King’s College, London. He is a senior associate of the Nuffield Trust and an honorary fellow of the Royal College of Physicians. iv © The King’s Fund 2013 Preface This short paper is built entirely on the work of others. It is a cross between a scream of rage and a call to arms. Within the boundaries of the United Kingdom there are four health systems that to the untutored eye – to the view from Mars so to speak – look essentially the same. At best, they appear to be minor variations on a theme – certainly not different symphonies, let alone different symphonies written by different composers. Yet thanks to longstanding historic differences and, more importantly, to the more recent devolution of political power within the United Kingdom, these four systems are diverging in all sorts of ways. The tunes to which they march are becoming noticeably different. From the point of view of anyone interested in policy – politician, civil servant, policy adviser, academic, member of the public – this should be a unique opportunity to compare, contrast and learn. It is an almost perfect test bed. But that isn’t happening. Or, to be fair, very little of it is happening. Where it is happening, there is too little of it. Something needs to be done to address that – and that is the central argument of this paper, which, in making the case, pejoratively or not, illustrates at least some of the differences that could be explored. This paper rests entirely on the work of others – Marcus Longley, David Steel, Pat McGregor, Ciarin O’Neill and Sean Boyle, who, along with Jon Cylus, Sherry Merkur, Cristina Hernandez-Quevedo and Sarah Thomson, have variously written and edited papers on the four countries in the European Health Observatory series ‘Health Systems in Transition’. This has been supplemented by a seminar and part of a conference at The King’s Fund and by teleconference calls around an early draft of this paper. That work in turn received strong support from Claire Mundle, Policy Officer at The King’s Fund, and Anna Dixon, the Fund’s Director of Policy. If there is any merit in what follows, it is all due to them. In order to produce something that we hoped would engage, it was clear that some broad judgements, or at least some broad observations, would have to be made. It was equally clear that not all the authors would or could agree on © The King’s Fund 2013 v The four UK health systems these. So, while this paper is built solely on their work, for which the Fund is immensely grateful, they are not bound in any way by the detail of what follows. Given the huge cultural and political sensitivities that lie around these issues, I would just also like to point out that while I was born in England and have lived there all my life, I have plenty of Celtic blood. This is not meant to be an Englishman’s superior view from his castle. If at any point it reads like that, it is an error of ignorance or interpretation, not of prejudice. Nicholas Timmins vi © The King’s Fund 2013 Introduction The National Health Service in the United Kingdom should be a policy analyst’s dream. Since 1999, devolution to Scotland and Wales, and the restoration of the Northern Ireland Assembly, has seen health policy and the way the NHS is run diverge in the four countries of the United Kingdom. The divergence in structures and management approaches, and indeed the differences in the way social care relates to health in the four countries, should provide a unique natural laboratory. In theory, by comparison and contrast over time, it should be possible to establish ‘what works’ in these different approaches, or at least some of ‘what works’ – even allowing for the fact that the populations of the four countries are not homogeneous in attitudes, characteristics, health behaviours or geography. In practice, the exercise is plagued with difficulty. Some of the key data needed to compare performance – including data on waiting times – is defined and collected differently in the four countries. Assembling such data over time to allow comparison is a significant undertaking. And there is, of course, a time lag between performance and information being available. Such studies are difficult. They will always be subject to a degree of interpretation, and their findings will sometimes be vigorously disputed. For all of that, these studies are far from impossible, and much more could be done to facilitate them. Indeed that is the central proposition of this paper. The Health Foundation, for example, in 2009 published a study of comparative clinical and quality indicators across the four countries (Sutherland and Coyle 2009). It showed differences in performance, though the differences were not all in one direction. The latest data it was able to use was from 2006, which predates both some of the policy divergence, and some areas where policy has moved more closely back in line between the countries – for example, the use of waiting time targets. In 2010, the Nuffield Trust produced a heroic effort comparing performance through activity, again relying on 2006 data as the latest then available (Bevan et al 2010). The results, however, were greeted more with denial than acceptance where performance appeared to be poorer. There seemed to be a greater willingness to pick holes in the data, or seek reasons, even excuses, for less good performance rather than confront the fact that there might be a real message here, despite the problems. The Nuffield Trust is currently updating the exercise. Such studies are and will remain controversial – an object lesson in the fact that the conclusions of © The King’s Fund 2013 1 The four UK health systems attempts at comparative studies across the United Kingdom will never command universal acceptance (McLaren et al 2010). Lack of universal acceptance, however, is not a reason not to conduct these studies. The fact that there are so few is due in large measure to politicians’ distinct lack of interest in – indeed at times hostility towards – the idea of encouraging such studies. Their reservations are often reflected in the view of many officials. The reason, one suspects, is that each of the four countries secretly fears that its approach to running the service might not stand up to such comparative scrutiny. Indeed, the situation is worse than that. Just as in some quarters across all four countries criticism of the NHS can produce powerful emotional responses of denial, even in the face of hard evidence, so questioning from within the countries about comparative performance between them is too often portrayed as somehow ‘disloyal’ – a betrayal of Scots or Welsh or Northern Irish identity. It is almost as if there are four ‘truths’ around the various versions of the NHS that should not be challenged. Certainly at the political level, there remains a tendency in Scotland and Wales in particular to define their health systems as ‘not England’. England is not immune to this. In England political dispute continues not just between but within parties over the application of an element of market principles to the NHS. But among those who are, for example, committed to the values of targets and performance management, or to choice or competition, there is a distinct reluctance to consider whether the differing approaches in the other three countries may on occasion produce better outcomes. In each of the four countries there is defensiveness over difference, and a reluctance to expose performance to the spotlight.